Pat Ferrier, Coloradoan
Chloe Carroll of Wellington woke up suffering from an allergic reaction, her face and body swollen and covered in hives.
James Carroll rushed his then-3-year-old daughter to the closest emergency room: Banner Fort Collins Medical Center on Harmony Road.
The doctor gave Chloe a shot of diphenhydramine — Benadryl — and sent her home. The swelling and hives returned the next day. This time, he took Chloe to their family doctor, who prescribed a different medicine that took care of the problem.
A few weeks later, Carroll received a $1,300 bill for Chloe’s emergency room visit.
The family has insurance and expected Anthem Blue Cross to pay the bill after their $150 co-pay. What they didn’t know was Banner Fort Collins’ emergency department was not contracted to accept their Anthem Blue Cross Blue Shield policy, even though its other facilities were. That meant Carroll was on the hook for the entire cost of Chole’s visit.
UCHealth phlebotomist Brenton Carroll works in the Harmony Campus lab that will soon be relocated to UCHealth’s freestanding emergency department on Harmony Road. (Photo: Photo by Kati Blocker, UCHealth.)
Carroll was caught in a quagmire of regulations, well-meaning but outdated laws, and a tangle of insurance contracts that govern where and by whom a patient is treated, contracts that are often unknown to outsiders.
Making the wrong choice can cost thousands of dollars in unexpected bills. Carroll knows he’ll eventually have to pay the bill, but he’s on a campaign to bring about change and transparency to emergency rooms.
After reading about a similar case in the Coloradoan last year, Carroll reached out to Sen. John Kefalas, D-Fort Collins, for help.
The bill
For the second year, Kefalas has introduced a bill that would create more transparency in billing and insurance at freestanding emergency rooms.
Senate Bill 146 would require a freestanding emergency department to provide information to patients about the public and private health plans it accepts, list the cost for the 25 most common health services it provides, and assure people they will be treated regardless of ability to pay.
After determining there is no emergency condition, doctors would have to provide a written disclosure that spells out the maximum charges the patient would be billed.
Carroll said his daughter was in no imminent danger and he would have taken her to UCHealth’s freestanding emergency department just blocks away had he known insurance wouldn’t cover the visit.
He appealed to the insurance company and the Department of Managed Care in California (where the insurance plan is based).
He paid $150 before leaving the emergency department, “more than the 10 percent we owed per our insurance policy,” but refused to pay the rest pending appeals of his bill.
His account was sent to collections, a lawsuit was filed in Larimer County court and he paid $92 to request a 90-day extension while his case was investigated. Both were denied. To add insult to injury, he received a 25-cent bill from the court for the cost of the paper on which his appeal was written.
His story is a familiar one: people with insurance going to the emergency room only to find their insurance will not cover the bill.
Banner officials said Kefalas’ bill would not apply to Banner Fort Collins emergency room because it is a hospital emergency department. They referred all other questions to the Colorado Hospital Association, which “is not opposed conceptually to the bill.”
CHA “has a long-standing history of supporting transparency,” CHA said in a statement. The association is working with bill sponsors on some technical changes needed in the bill “to keep hospitals in alignment with existing law.”
“One of the other clauses … requires hospitals to align/disclose facility fees with discharge diagnosis — which is not possible within the current delivery/payment system,” CHA spokeswoman Julie Lonborg said in an email. “The disclosure of the facility fee is not the issue — most hospitals posted those earlier this year.”
Banner officials said Anthem Blue Cross Blue Shield contracts with McKee Medical Center in Loveland and North Colorado Medical Center in Greeley, but not Banner Fort Collins Medical Center.
Banner “remains in discussions with Anthem Blue Cross Blue Shield and would welcome the opportunity to work with them on behalf of our patients at Banner Fort Collins Medical Center,” spokesman Sara Quale said.
Carroll said he’s caught in a “a political fight. It’s dirty every which way you look at it.” He wants to know why he wasn’t told about the insurance issue before his daughter was treated.
‘Hands are tied’
Health care providers say their hands are tied by a federal law and complex insurance landscape that prevents them from discussing insurance or a patient’s financial status. It’s called the Emergency Medical Treatment & Labor Act, or EMTALA, which was designed to ensure a person’s inability to pay did not prevent them from seeking medical treatment.”
Once a patient enters the emergency department with a health concern, staff is not permitted to ask about insurance coverage if it delays treatment, Banner has said previously.
Last year’s bill was shot down partially out of fear it violated EMTALA laws, Kefalas said.
This year, he worked with the Region 8 Health and Human Services director, hospitals and fellow legislators to ensure SB-146 would not violate EMTALA. The bill would require prescreening to occur before the information was presented.
If a person was not in immediate danger, the patient would be provided information about the potential costs of treatment so they could make an informed decision, Kefalas said.
UCHealth spokesman Dan Weaver said the health system “supports greater transparency and sharing information about prices and care with patients.”
However, he said the state should not place hospitals and providers in a position where they might violate the federal EMTALA law. “We would also be concerned about any excessive burdens that could take providers away from caring for patients.”
Who it applies to
Senate Bill 18-146 applies only to freestanding emergency departments and those located more than 250 yards from the main campus. It would not apply to Banner Fort Collins’ Emergency Department, which is physically attached to the medical center, or hospitals like Poudre Valley Hospital, McKee Medical Center or Medical Center of the Rockies.
It would cover UCHealth’s freestanding emergency rooms in Fort Collins and Greeley.
The bill specifically states the patient should be assessed for a critical emergency because it does not want someone suffering from a heart attack, for example, to delay immediate treatment.
Unlike last year, when the similar bill died in committee, Kefalas has bipartisan support for SB-146. It sailed through committee and Kefalas is reasonably confident it will pass the Senate and House.
“SB 146 is trying to hold freestanding emergency departments accountable and make sure consumers have the information they need to make the best decisions for themselves,” said Adam Fox, director of strategic engagement for the Colorado Consumer Health Initiative, which represents more than Colorado health organizations advocating for high-quality, affordable and equitable health care for all Coloradans.
“The goal is to make sure consumers aren’t hit by unnecessarily high medical bills. Especially in the areas where these freestanding emergency departments have popped up, a lot of people think they are urgent care or because it’s a small facility the costs will be smaller than going to an emergency room connected to a hospital,” he said. “They end up walking out with large facilities fees and they end up paying more than they expect.”
ER or urgent care?
CCHI argues that part of the need for transparency at freestanding emergency departments is because people have difficulty distinguishing between an urgent care center and freestanding emergency room.
They can often look like urgent care, but emergency departments, whether freestanding or not, carry a facilities fee that pays to provide nurses, staffing, technology, housekeeping, security and other essential services around the clock. It is the most expensive place to receive care.
“People have unexpectedly ended up with inflated medical bills because the average cost of treating common, non-emergent conditions at freestanding ERs can be up to 20 times higher than at physician offices and urgent care centers,” CCHI said in a statement.
Kefalas believes his bill has widespread bipartisan support because legislators are hearing from their own constituents about unexpected high costs they incurred when they thought they had no other, less expensive options.
Katie Fauvelle of Thornton said she ended up at a UCHealth freestanding ER that was out of her insurance network even though other UCHealth facilities were in network. No one ever mentioned the facility was out of network, she said.
Six weeks later she received a bill from UCHealth for $10,995.77, including $6,790.71 for “emergency services“ with no other detail.
“We felt like UCHealth was charging us whatever they wanted without any justification, and now they’re threatening to send us to collections. SB-146 could have helped me know what I was walking in to.”
While freestanding emergency departments are sparse in Northern Colorado, they are proliferating in Denver.
As of late January, there were 50 freestanding emergency departments in the state, including UCHealth on Harmony Road, according to Joe Hanel, associate director of strategic communications for Colorado Health Initiative, a nonpartisan, health-care analysis group.
While freestanding emergency rooms first claimed they would fill a need for emergency care in rural and underserved areas that could not financially sustain a traditional hospital, they are being built in affluent areas where there are already adequate emergency services nearby, Hanel said.
Pricing
Banner and UCHealth have both posted some pricing on their websites.
ForBanner, go to bannerhealth.com, scroll to the bottom of the page and under “patients and visitors,” click on billing information, then on “common prices,” then Colorado. The scroll down and select the area you want, such as hospital inpatient or emergency. Then scroll to the bottom and click where it says “read more.”
For UCHealth, go to uchhealth.org, scroll to the bottom and click on billing and pricing. Scroll down to pricing, then insured and uninsured patients and click on uninsured. Scroll down and choose the hospital you are looking for. Then choose outpatient, emergency or inpatient services. You will find a list of some common procedures, such as lab. In the emergency area it will show five levels of emergency department services. These are self-pay prices only.
Know in case of emergency
Nobody expects an emergency. Emergency room personnel say it is critical for patients to understand their insurance coverage and provider network before an emergency happens. Ask your provider:
- What hospitals and doctors are in my provider network? Where can I find a list?
- What benefits exist when I receive care out-of-state, or outside my network of providers? What is it is emergency care?
- What co-payments should I expect when I receive care?
Emergency admissions
Hospital Inpatient admissions from ED ED visits
2015 / 2017 2015 / 2017
Banner Fort Collins 278 * / 465 5,932 / 8,290
McKee Medical Ctr 2,515 / 2,190 26,261 / 23,519
Medical Ctr of Rockies 5,192 / 5,965 53,547 / 55,990
North Colo Med Ctr 5,857 / 5,775 54,007 / 48,759
Poudre Valley Hospital 6,669 / 7,048 57,613 / 65,483
* Banner Fort Collins Medical Center opened in March 2015
Data compiled by Colorado Hospital Association